FINGERPRINT BACKGROUND WAIVER
CPE Form 40c – Background Investigation
SECTION 1/FINGERPRINT BACKGROUND WAIVER
|APPLICANT’S LAST NAME (PRINT LEGIBLY) |APPLICANT’S FIRST NAME |POSITION AT SCHOOL |
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|APPLICANT’S ADDRESS |APPLICANT’S CITY/ST/ZIP |APPLICANT’S HOME OR CELL PHONE # |
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|LIST ALL FELONY OR CRIMES OF MORAL TURPITUDE CONVICTIONS. USE ADDTIONAL PAPER IF NEEDED. IF NONE, WRITE NONE IN YEAR FIELD. |
|YEAR |CITY/STATE |CONVICTED OF |SENTENCE |
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|As an applicant who is the subject of a Federal Bureau of Investigation (FBI) fingerprint-based criminal history record check for a noncriminal justice purpose |
|you have certain rights which are discussed below. |
|1. You must be notified by the Commission on Postsecondary Education that your fingerprints will be used to check the criminal history records of the FBI and |
|the State of Nevada. |
|2. If you have a criminal history record, the officials making a determination of your suitability for the job, license or other benefit for which you are |
|applying must provide you the opportunity to complete or challenge the accuracy of the information in the record. You may review and challenge the accuracy of |
|any and all criminal history records which are returned to the submitting agency. The proper forms and procedures will be furnished to you by the Nevada |
|Department of Public Safety, Records Bureau upon request. If you decide to challenge the accuracy or completeness of you FBI criminal history record, Title 28 |
|of the Code of Federal Regulations Section 16.34 provides for the proper procedure to do so: |
|16.34 - Procedure to obtain change, correction, or updating of identification records. |
|If, after reviewing his/her identification record, the subject thereof believes that it is incorrect or incomplete in any respect and wishes changes, |
|corrections or updating of the alleged deficiency, he/she should make application directly to the agency which contributed the questioned information. The |
|subject of a record may also direct his/her challenge as to the accuracy or completeness of any entry on his/her record to the FBI, Criminal Justice Information|
|Services (CJIS) Division ATTN: SCU, Mod. D-2, 1000 Custer Hollow Road, Clarksburg, WV 26306. The FBI will then forward the challenge to the agency which |
|submitted the data requesting that agency to verify or correct the challenged entry. Upon the receipt of an official communication directly from the agency |
|which contributed the original information, the FBI CJIS Division will make any changes necessary in accordance with the information supplied by that agency. |
|3. Based on 28 CFR § 50.12 (b), officials making such determinations should not deny the license or employment based on information in the record until the |
|applicant has been afforded a reasonable time to correct or complete the record or has declined to do so. |
|4. You have the right to expect that officials receiving the results of the fingerprint-based criminal history record check will use it only for authorized |
|purposes and will not retain or disseminate it in violation of federal or state statute, regulation or executive order, or rule, procedure or standard |
|established by the National Crime Prevention and Privacy Compact Council. |
|5. I hereby authorize Commission on Postsecondary Education to submit a set of my fingerprints to the Nevada Department Public Safety, Records Bureau for the |
|purpose of accessing and reviewing State of Nevada and FBI criminal history records that may pertain to me. In giving this authorization, I expressly |
|understand that the records may include information pertaining to notations of arrest, detainments, indictments, information or other charges for which the |
|final court disposition is pending or is unknown to the above referenced agency. For records containing final court disposition information, I understand that |
|the release may include information pertaining to dismissals, acquittals, convictions, sentences, correctional supervision information and information |
|concerning the status of my parole or probation when applicable. |
|6. I hereby release from liability and promise to hold harmless under any and all causes of legal action, the State of Nevada, its officers, agents and/or |
|employees who conducted my criminal history records search and provided information to the submitting agency for any statement(s), omission(s), or |
|infringement(s) upon my current legal rights. I further release and promise to hold harmless and covenant not to sue any persons, firms, institutions or |
|agencies providing such information to the State of Nevada on the basis of their disclosures. I have signed this release voluntarily and of my own free will. |
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|A reproduction of this authorization for release of information by photocopy, facsimile or similar process, shall for all purposes be as valid as the original. |
|In consideration for processing my application I, the undersigned, whose name and signature voluntarily appears below; do hereby and irrevocably agree to the |
|above. Click here for more information concerning your rights. |
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|SIGNATURE OF APPLICANT |DATE SIGNED |
|SECTION 2/SCHOOL INFORMATION |
|NAME OF SCHOOL |PRINTED NAME OF SCHOOL OFFICIAL |SCHOOL OFFICIAL’S POSTION |
| | |SCHOOL OFFICIALS PHONE NUMBER |
|I certify that I have reviewed the information on this form as provided by the applicant. |
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|SIGNATURE OF SCHOOL OFFICIAL/DATE SIGNED |
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|SECTION 3/CPE INFORMATION |
|Commission on Postsecondary Education |PRINTED NAME OF CPE STAFF | |
|8778 S Maryland Pkwy #115 | | |
|Las Vegas NV 89123 | | |
| |SIGNATURE OF CPE STAFF | |
|SECTION 4/ENTITY TAKING FINGERPRINTS (Do not process without CPE staff signature and stamp) |
|STAMP/SIGNATURE OF ENTITY TAKING AND SUBMITTING FINGERPRINTS |DATE |
| |TCN # |
Return completed form to CPE by mail or email to sbeckett@cpe.state.nv.us
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